Biographic Data
Mr. X is a 50-year-old man from Texas. He is a retired civil engineer who stays at home with his wife and two children. The social activities which he currently engages in are rearing animals on his ranch. Also, Mr. X is a Christian of the African American race. The patient has a positive family history of cardiac diseases. He has a history of smoking cigarettes and drinking alcohol. The client engaged in a road traffic accident two days earlier but was treated for minor chest injuries and was discharged home. The patient has no known drug addictions or food allergies.
Subjective Findings
The patient arrived at the outpatient clinic accompanied by his wife and elder son. He was complaining of acute chest pain, which started 12 hours ago. The chest pains are felt beneath the sternum. The client describes the pain as a sharp sensation that radiates to the neck and the arms. On a scale of 1 to 10, he rates the chest pain as 9/10. The chest pain is intermittent in duration and is aggravated when the patient lies down in a supine position. Worsening of the chest pain also occurs when the patient breathes in deeply. The client reports that the pain is relieved when he assumes a forward-leaning role and sits down. Additionally, the patient takes over-the-counter analgesics for the chest pain without any changes in the severity.
Objective Findings
A targeted physical examination of the cardiovascular system is required to get a clearer understanding of the patients symptoms. Generally, the patient appears to be in discomfort and frequently changes positions to find comfortable poses. On auscultation of the chest, a leathery sound was heard at the fourth intercostal space, at the left sternal border, when the diaphragm of the stethoscope was placed tightly against the thorax. This scratching sound was heard best when the patient was sitting down. The sound was also loudest at the end of expiration by the patient. Furthermore, auscultation showed distant s1 and s2 heart sounds.
On the nurse’s further objective assessment at the clinic, the jugular vein was extended. There were mild lacerations on the chest and the breathing rate of the patient was 12 beats per minute. The heart rate was found to be at 100 beats per minute, and pulses were observed. The blood pressure was at 100/70 mmHg, and the patient’s temperatures were found to be elevated at 38.2 degrees Celsius. Chest x-ray showed a mild globular shadow of the heart. Electrocardiography was done, which portrayed diffuse ST-segment elevations with an accompanying concavity. The PR segment was also depressed. Laboratory findings showed that the white blood cell count was significantly raised, and the erythrocyte sedimentation rates were also elevated.
Risks
Assessment findings indicated that the patient is at risk of having a pericardial effusion which is the fluid accumulation in the pericardial space. This is due to the mild globular shadow on the chest x-ray, which indicates the potentiality of pericardial fluids. Another potential complication from the assessment findings is the risk of impairment in the heart’s ability to function. This is due to the hemodynamic instabilities evidenced by the low blood pressures of 100/70mmHg and the muffled heart sounds (Ismail, 2020). The inflammation of the pericardium can also result in the decreased elasticity of the pericardium (constrictive pericarditis), which is evidenced by the jugular vein distention due to the growing difficulty of filling the heart.
References
Ismail, T. F. (2020). Acute pericarditis: Update on diagnosis and management. Clinical Medicine, 20(1), 48–51. Web.